DS-13-2531 t '
a Miami Shores Village RECEIVED
Building Department
O
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel: (305)795.2204 Fax: (305)756.8972
INSPECTION'S PHONE NUMBER: (305)762.4949
FBC 20
BUILDING Permit No.
PERMIT APPLICATION master Permit No.�
Permit Type: BUILDING ROOFING
JOB ADDRESS: 11-7 A ZV l I
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated:Yes NO Flood Zone:
OWNER:Name(Fee Simple Titleholder): l '� Phone#: 7 6 1 l
Address: 6
City: ® State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: K. S ('�S�] 'x '�7 f�/I S -QAt V e�r I /h0'Phone#:"-16 6 - T75 J-5 7
Address: g19D0 .W Wo
City: �1i'�,.,y State:CT"!) CL Zip: jq�3 l
Qualifier Name: _ Phone#: -79& -q76 " Y�Z
State Certification or Registration#: 154 Certificate of Competency#:
Contact Phone#: o - C37 SV Ema; Ad-dress: 'ft'l j n rh,l le�c I rna�
DESIGNER: Architect/Engineer: p` Phone#:
Value of Work for this Permit: $ q 20 Square/Linear Footage of Work: 00-S( '�}
Type of Work: ❑Addition IKlteration ❑New ❑Repair/Replace ❑Demolition
Description of Work:
�.. _ Color thru tile:
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$ O
T f
Bonding Company's Name(if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK,PLUMBING, SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and AIR CONDITIONERS,ETC.....
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must
promise in good faith that a copy of the n tice of commencement and construction lien law brochure will be delivered to the person
whose property is subjec attachment. lso, certified copy of the recorded notice of commencement must be posted at the job site
for the first ins ction ich occurs se n (7) ays after the building permit is issued. In t e absenc such posted notice, the
inspection wil n t be p o'i and a ei specti fee will be charged.
Signature Signature
�wner o Agent Contractor
The foregoing instrument was acknowledged before me this The forego-- P
i ng instrumen was acknowledged before me this
day of OkO ,20 ,by �S-e 4 aA day of A tv J 20 L,by � n A
who is personally known to or who has produced < who is personally know to who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: �L Print: -
My Commission Expires: onnY P$e� MYIAI HERNMEZ My Commission
+: MY C06rdISSION k EE 221249 �`y�F' MYLAI HERNA{dDQ
5*;
r; EXPIRES:December 1,2016 my COATAISSION R EE 221249
FtF� ,n Bonded Thru Notary Public Underwriters .;: SPIRES:December 1,2016
off'. Bonded Thru Notary Public undeiu bm
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APPROVED BY 0 t 144 4 Plans Examiner l r l /Zoning
Structural Review Clerk
(Revised 5/2/2012)(Revised 3/12/2012)XRevised 06/10/2009)(Revised 3/15/09XRevised 7/10/2007)